Understanding the factors contributing to poor treatment adherence, recognizing its consequences, and developing effective strategies to enhance adherence are key to improving patient outcomes in lupus.

Non-adherence in systemic lupus erythematosus (SLE) and lupus nephritis (LN) is a significant issue, with reported rates ranging from 3–83% depending on the assessment methods used.^{1 2} The highest rates are observed in studies using objective measures, and non-adherence is particularly prevalent in countries without health insurance systems and limited access to specialized care.

Treatment adherence in SLE and LN is often hindered by multiple factors. Socioeconomic challenges, such as financial constraints and limited access to healthcare, play a significant role. Additionally, the complexity of treatment regimens, which often include multiple medications with potential side effects, can overwhelm patients. Psychological barriers, including depression and anxiety, further complicate adherence. Understanding these factors is essential for healthcare providers to tailor interventions effectively.

Diagnosing non-adherence accurately is the first step in addressing this challenge. This can be difficult due to the variability and limitations of current assessment methods. Published recommendations (e.g. EULAR), emphasize a non-judgmental approach and patient empowerment.³ For patients with SLE and LN, non-adherence has serious clinical implications, including increased disease activity and progression to end-stage renal disease (ESRD).⁴ Renal transplantation can be life-prolonging for patients reaching ESRD, with better survival and fewer complications compared to dialysis.⁵ Poor adherence to immunosuppressive therapy, however, increases the risk of graft failure. Therefore, it should be routinely assessed at each visit, as adherence behaviours can evolve over time. Open, non-judgmental discussions about adherence can prevent renal flares and unnecessary treatment escalation.

Emerging treatment paradigms for SLE and vasculitis, including steroid dose reduction and newer medications with better side-effect profiles, offer hope for improved adherence.⁶ These advances alone are, however, insufficient. Building rapport, enhancing patient self-efficacy, and involving patients in care decisions remain essential strategies for improving adherence and patient outcomes.

This presentation will review studies looking at non-adherence in SLE and LN and a comparison between adherence patterns in lupus and other autoimmune rheumatic diseases.

References

1. Costedoat-Chalumeau N, Pouchot J, Guettrot-Imbert G, et al. Adherence to treatment in systemic lupus erythematosus patients. Best Pract Res Clin Rheumatol. 2013;27(3):329–40. doi: 10.1016/j.berh.2013.07.001.

2. Feldman CH, Yazdany J, Guan H, et al. Medication nonadherence is associated with increased subsequent acute care utilization among medicaid beneficiaries with systemic lupus erythematosus. Arthritis Care Res (Hoboken). 2015;67(12):1712–21. doi: 10.1002/acr.22636.

3. Ritschl V, Stamm TA, Aletaha D, et al. 2020 EULAR points to consider for the prevention, screening, assessment and management of non-adherence to treatment in people with rheumatic and musculoskeletal diseases for use in clinical practice. Ann Rheum Dis. 2021;80(6):707–13. doi: 10.1136/annrheumdis-2020-218986.

4. Ntatsaki E, Isenberg D. Risk factors for renal disease in systemic lupus erythematosus and their clinical implications. Expert Rev Clin Immunol. 2015;11(7):837–48. doi: 10.1586/1744666x.2015.1045418.

5. Ntatsaki E, Vassiliou VS, Velo-Garcia A, et al. Renal transplantation for lupus nephritis: Non-adherence and graft survival. Lupus. 2019;28(5):651–57. doi: 10.1177/0961203319842641.

6. Ntatsaki E, Ali B, Hamour S, et al. AB1242 comparing adherence to treatment in lupus and vasculitis patients. Ann Rheum Dis. 2018;77(Suppl 2):1717. doi: 10.1136/annrheumdis-2018-eular.5932.

Learning Objectives At the end of this presentation participants will be able to:

• Discuss the factors contributing to poor compliance: Identify and explain the various factors (such as socioeconomic status, medication side effects, complexity of treatment regimens, and psychological barriers) that contribute to poor compliance in patients with LN

• Diagnose non-adherence using effective tools: Learn to accurately diagnose non-adherence in SLE and LN patients by utilizing various assessment tools and methods. Emphasize the importance of routine and open discussions about adherence during each patient visit to prevent renal flares and unnecessary treatment escalation

• Develop strategies to improve compliance: Explore and evaluate different strategies and interventions aimed at improving patient compliance